Stress & Adrenal Quiz Section 1

Name*

First Last

Email*

Date*

At which Revitalize Health location are you a patient?*

I have constant stress in my life and/or work*

Never	Occasionally	Often	Always

My dietary habits tend to be sporadic and unplanned*

Never	Occasionally	Often	Always

My relationships at work and/or home are unhappy*

Never	Occasionally	Often	Always

My life contains insufficient enjoyable activities*

Never	Occasionally	Often	Always

I overwork with little play or relaxation for extended periods*

Never	Occasionally	Often	Always

I am too busy to do routine things*

Never	Occasionally	Often	Always

I have one or more chronic illnesses or diseases*

Never	Occasionally	Often	Always

I have diabetes (Type II, adult onset, or non-insulin-dependent diabetes mellitus--NIDDM)*

No	Yes

I have low blood pressure*

Never	Occasionally	Often	Always

I tend to gain weight, especially around the middle (spare tire)*

Never	Occasionally	Often	Always

I wake up tired even after 6+ hours of sleep*

Never	Occasionally	Often	Always

I'm tired at night, but have trouble falling asleep*

Never	Occasionally	Often	Always

I am usually exhausted at bedtime, but my mind won't stop racing*

Never	Occasionally	Often	Always